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Bidirectional eReferrals Between Health
Systems and YMCAs
Session 83, February 12, 2019
Kate Kirley, MD, MS, FAAFP, Director, American Medical Association
Mamta Gakhar, MPH, Director, YMCA of the USA
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Kate Kirley, MD, MS, FAAFP and Mamta Gakhar, MPH
have no real or apparent conflicts of interest to report.
Conflict of Interest
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• Overview of type 2 diabetes prevention
• Exploration of bi-directional referral approaches
• Y-USA/CDC/AMA e-referral project summary
• Discussion of key drivers for bi-directional referral
• Recommendations for health systems and LCPs
Agenda
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• Describe the key components of bi-directional referral processes
between healthcare providers lifestyle change programs to prevent
type 2 diabetes
• Identify different approaches/examples of utilizing technological
solutions to facilitate bi-directional communication between healthcare
providers and lifestyle change programs
• Discuss key drivers health systems and lifestyle change programs
should consider when implementing technological solutions to
facilitate bi-directional referrals
• Summarize recommendations for healthcare provider organizations
and lifestyle change programs with different levels of HIT
sophistication
Learning Objectives
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Overview
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There are 262,800 minutes in a year. What percentage of that time
does the average person spend at their doctor’s office?
A. <0.1%
B. About 1%
C. About 5%
D. About 10%
Audience response question
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Evidence for the National DPP LCP
DPP Research Study: People with prediabetes who took part in a structured lifestyle
change program reduced their risk of developing type 2 diabetes (at average follow-up of 3
years) compared to placebo. And the lifestyle change program was nearly twice as
effective as metformin.
DPP
Intensive Lifestyle Change Program
(71% reduction for patients age 60 and older)
METFORMIN
Glucose Lowering Drug
(Currently, FDA does not approve the use of
metformin for type 2 diabetes prevention)
31%
risk
reduction
58%
risk
reduction
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LCP side: Y-USA lifestyle change
program
The YMCA’s Diabetes Prevention
Program is:
• Led by a trained Lifestyle Coach
• A year-long program: 25 sessions
• A Centers for Disease Control and
Prevention (CDC) - approved
curriculum
Program goals:
• Reduce body weight by 5-7%
• Increase physical activity to 150
minutes per week
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What are Bi-Directional Referrals?
A bi-directional referral considers both the information (referral)
going from the HCP to the LCP, as well as information (feedback)
going back to that referring HCP.
Bi-directional referrals
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0
Lifestyle
Change
Program
Healthcare
Provider
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Have you attempted to implement bi-directional e-Referrals
between a clinical organization/provider and a non-clinical
organization/provider
A) Yes
B) No
Audience response question
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• Emphasizes prevention and the role of healthcare outside the clinical
setting
• Ensures that information is moving both from the HCP to the LCP and
from the LCP back to the HCP
• Increases # of touchpoints with patients which may increase likelihood for
them to enroll or improve their health outcomes
• Allows HCPs to reinforce positive behaviors demonstrated when feedback
is provided on a patient’s program progress
• Keeps the LCP front of mind for HCPs, which may result in a greater
number of referrals being made
• Improves care continuity for the patient by establishing the LCP as a
practice extender and member of the care team
• Establishing a bi-directional referral pathway can be beneficial to
HCPs and LCPs alike, and ultimately enhance the patient experience
and improve health outcomes
Importance of bi-directional referrals
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2
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Project Summary
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Original Project Goals:
• Increase clinic to community linkages
for bi-directional e-referrals by working
with health care providers to identify
pathways for e-referrals and sharing
participant program outcomes
• Develop and document best practices
for successful use of bi-directional e-
referral models
DPP e-referral project overview
With funding from CDC’s Division of Diabetes Translation, YMCA of the
USA, the American Medical Association, and CDC worked with four local
providers of the YMCA’s Diabetes Prevention Program to build and
implement bi-directional e-referral communication pathways with existing
health care partners
Revised Project Goals:
• To gain a better understanding
of the factors (EHR functions)
to consider when approaching
implementation of bi-
directional e-referrals based
on the learnings gained from
local Ys and their health care
partners throughout project
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4
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Local Project Partners and EHRs
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YMCA
YMCA
EHR
Healthcare Partner
Partner
EHR
YMCA of
Greater
Seattle
athenaNet
Multicare
Health System
Epic
University of Washington
Medicine
Epic
YMCA of
Greater
Kansas City
athenaNet
Shawnee Mission Health
athenaNet
Truman Medical Center
Cerner
YMCA of
Greater
New York
athenaNet
Mt. Sinai Health System
Epic
New York University Medical
Center
Epic
YMCA of
Greater
Delaware
athenaNet
Quality Family Physicians
Centricity
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The bi-directional e-referral pathway
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Patient visits HCP, is
screened for prediabetes,
provides consent for
referral
HCP refers to LCP via
e-referral, includes key
info
LCP contacts patient,
confirms qualification and
interest, enrolls into
program
LCP provides electronic
updates to HCP on
patient progress once
program starts
HCP monitors patient
progress, reinforces
behavior change with
patient at next visit
Supporting
ongoing process
improvement:
relationship-
building,
communication,
aggregate data
Supporting
ongoing process
improvement:
relationship-
building,
communication,
aggregate data
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Remote Call Fax Forwarding
(Referral)
• Analog fax line forwards either
electronic or paper fax into
EHR
• Typically easy to implement,
especially if HCP is already
using fax as primary referral
method
Direct messaging (Referral)
• Fully electronic communication
from EHR to EHR
• Can be difficult to implement if
not part of existing clinical
workflows
athenaNet methods tested
Clinical Letters (Feedback)
• Templates with key phrases
that auto-fill patient specific
info; sent electronically to
HCP via EHR
• Creates challenges closing
feedback loop as only
patients registered in EHR
can have letters sent
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Project outcomes
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8
52
11
2
53
72
83
84
184
YMCA A YMCA B YMCA C YMCA D
# of referrals
423 e-referrals received over the
course of the project
Each Y experienced an increase over baseline
from referring HCPs
Baseline (Q2-Q4 2016) Project Period (Q2 2017-Q2 2018)
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If you work in a healthcare delivery organization, how many different
EHRs does your organization currently utilize?
A) None
B) 1
C) 2-5
D) 6 or more
Audience response question
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Key Drivers
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• Organizational strategy
• Relationship development
• Resource needs
• Technology and EHR use
• Interoperability
• Data security and handling
Key drivers and barriers
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= Healthcare provider organizations (HCPs)
= Lifestyle change programs (LCPs)
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Organizational strategy
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Relationship development
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Resource needs
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Technology and EHR use
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Interoperability
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Data security and handling
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Learnings and
Recommendations
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The relationship is the centerpiece
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• Leverage existing relationships
• Form new relationships
• Identify your intended audience type
Find the right
people
• Ask questions to understand both
organizations “pain points”
• Ask questions to understand the value each
organization provides to the other
Address key
needs
• Use conversations to inform your strategy
and build relationships
Define your
opportunity
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HCPs
• Project Lead
• Physician Champion
• Population Health Manager or
Physician Practice Manager
• Health IT staff
• Marketing/communications staff
LCPs*
• Project Lead
• Project support
• IT staff
• Program Manager
• Lifestyle Coach
• Data entry specialist
Establishing a project team
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Using a team-based approach can increase buy-in and
accountability and ensure continuity in the event of staff turnover
*one individual may fulfill multiple roles
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Project Lead – coordinates and leads planning and implementation activities,
often taken on by one of the other team members outlined below
Physician Champion – engages other physicians and the care team to raise
awareness, engages leadership to gain organizational buy-in, and supports
care team training
Population Health Coordinator/Manager or Physician Practice
Leader/Manager – coordinates design of referral workflow from physician to
LCP
Health IT Staff Person – supports the Project Lead in using EHR to identify
patients and assist in leveraging EHR for queries, registries, reporting, etc.
Marketing/Communications Staff – develops and launches patient
communication materials and ensures that your program continues to reach
new patients
For HCPs: Key team members
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For LCPs: Key team members
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Project Lead – coordinates and leads all activities around planning and
implementation, often taken on by one of the other team members outlined
below
Project support – provides additional administrative support to project
IT Staff – supports Project Lead in identifying/testing system functionality for
receipt of inbound referrals and data sharing with HCPs
Program Manager – manages implementation of lifestyle change program,
conducts enrollment conversations with referred patients
Lifestyle Coach – facilitates lifestyle change program, primary relationship-
holder with patient
Data entry specialist – enters patient and program data into EHR
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• Work collaboratively to ensure mutual understanding on timeline,
communication channels, staff roles, & plans for ongoing
evaluation
• Develop workflows (building off existing workflows) feasible for
implementation. Incorporate processes for:
• how referrals will be handled once received
• information needed as part of referral
• information needed as part of feedback loop
• how/when data can be shared
• how success will be measured
• Confirm any required legal agreements and HIPAA practices are
in place
Project planning and scope
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Implementation and evaluation
•Begin
implementation
ASAP and
focus on joint
and immediate
problem
solving
•Consider
starting initially
with paper
referrals to
streamline
process
•Be prepared to
test different
approaches
over time to
find out which
works best
within the
context of each
partnership
Communicate
regularly to
share
feedback, and
use data when
possible to
assess your
work and
recalibrate your
work
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Identify project team
Select LCP offering – internal or external
Train health care team on process
Identify eligible patients
Determine and enact patient engagement process
Generate patient referral to LCP
Select process for communicating patient’s clinical progress between referral source and LCP
Recommendations for HCPs: Utilize a
project management approach
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• Secure leadership buy-in by tying to other organizational priorities
• Engage key stakeholders early (internal and external)
• Use existing people, processes, and tools when possible
Infrastructure used for managing diabetes can be leveraged
to prevent type 2 diabetes
• When seeking a new solution, choose one that can apply to other
initiatives/conditions
• Work with varying levels of HIT
• Plan for care team engagement training, and repeat
• Start low-tech to learn, then phase in tech to scale
For HCPs: Other pearls
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• Identify current approach, resource needs, and future goals
• Develop a pitch to demonstrate program value – incorporate national statistics
and local program/community data into this pitch
• Talk to health system partners to see how they work with other non-traditional
providers of services; they may have a solution that works
• Develop a working knowledge of the EHRs that will be used to generate and
receive referrals
• Become familiar with EHR add-on modules or non-EHR platforms or software
(Par8o, Aunt Bertha, REDCap, ReferralMD, Fibroblast, etc.) that can be used
to facilitate linkages with the healthcare community
• If operating without an EHR, consider working with a Health Information
Service Provider to explore options for e-referrals
• Each partner may be unique and require slightly different approaches for bi-
directional communication – be flexible!
Recommendations for LCPs: Other
pearls
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Future focus and
exploration
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• Continued support of clinic-to-community linkages among networks
• Implementation of FHIR (fast healthcare interoperability resources)
standards for bi-directional communication and compatibility with
systems (both EHR, and non-EHR)
• Leveraging referral management solutions and Health Information
Exchanges
• Defining opportunities for LCPs to capture and share other
meaningful data to inform patient care (e.g., behavior change
strategies, social determinants of health)
• Demonstration of financial impact in value-based care
Future focus and exploration
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